Archive for the ‘CVS’ Category

Trop tops?

Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome: a systematic review.

Sylvie R. Stacy, et al

Ann Intern Med. Published online 12 August 2014 doi:10.7326/M14-0746 Continue reading

Esmolol in septic shock

Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial.

Morelli A1 et al

JAMA. 2013 Oct 23;310(16):1683-91. doi: 10.1001/jama.2013.278477.

STUDY APPRAISER: Dr David Smith Continue reading

A Black Water Day ?

Mortality after Fluid Bolus in African Children with Severe Infection. Maitland, K et al. New England Journal of Medicine, May 26th 2011 (epub ahead of print) (DOI: 10.1056/NEJMe1105490)
An interesting paper published in this weeks NEJM will cause substantial comment and concern after it’s headline result showed increased mortality with rapid fluid resuscitation in paediatric sepsis. This surprising result is potentially extremely important as, if verified, undermines much of peadiatric (and adult)emergency care.

Before examining the paper in detail it’s worth making a few comments on what we think we know already….

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SOAP II – That’s cleaned that up then.

Dopamine has been the vasopressor of choice in septic patients in continental europe historically, although this may be changing. Dopamine has theoretically beneficial effects in maintaining splancnic and renal perfusion although in the SOAP trial (observational) suggested that there was an excess of mortality of dopamine treated patients. The old story of “renal dose dopamine” having an additional effect over and above the improvement in perfusing pressure has been discredited, but this result suggests a harmful signal over and above noradrenaline (the preferred agent in the UK).

Comparison of dopamine and norepinephrine in the treatment of shock. De Backer DN, et al. N Engl J Med. 2010 Mar 4;362(9):779-89.
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Dopexamine & Meta-analysis

Meta-analyses of the effects of dopexamine in major surgery: do all roads lead to Rome? J. J. Pandit. Anaesthesia. 64;6:585-8. (Editorial)

Meta-analyses of the effect of dopexamine on hospital mortality. Gopal et al. Anaesthesia. 64;6:589-94.

Effect of dopexamine infusion on mortality following major surgery: individual patient data multi-regression analysis of published clinical trials. Crit Care Med. 2008 Apr;36(4):1323-9

Two recent meta-analysis have been published in answer to the question “does dopexamine reduce mortality in high risk general surgical patients”, with conflicting results. Pearse’s group found no difference in mortality using the entire data set, but a 50% mortality reduction with low-dose infusions. Gopal’s group found no difference using essentially the same data set, but a different statistical methodology. Panjit’s accompanying editorial does an excellent job of dissecting out why such apparent large differences might arise from the same data, and is recommended.

The take home message for me is that the results of combining heterogeneous studies together into meta-analysis tell us more about the statistical method than they do about the clinical question. Does dopexamine have a role? Is it the dopamine renal failure story all over again? I’m afraid we’ll need more data…..



Non Invasive Ventilation in Acute Cardiogenic Pulmonary Edema

Non-Invasive Ventilation in Acute cardiogenic Pulmonary Edema. Gray, A et al. NEJM, 2008. 359: 142-51. (or here on pubmed)

The “3 interventions in Cardiogenic Pulmonary oedema trial (3CPO)” trail was a multicentre, open, prospective randomised trial. 1069 patients were randomised over 4 years in 23 different centres in the UK. 3 treatment arms, all targeted to achieve sats >92%. 1: Oxygen, 2: CPAP 5-15cmH20 and 3: BiPAP 8-20/4-10.

Previous trials have suggested a reduction in intubation rates and a mortality benefit for CPAP or NIV, but some concerns over an increased MI rate with NIV.

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